Is Your Culture of Safety Psychologically Safe?

Laura M. Cascella, MA, CPHRM

The concept of psychological safety is increasingly viewed as a critical component of an overall culture of safety in healthcare. Leaders and other individuals within healthcare organizations have seen the value of psychological safety in promoting an environment of caring and well-being, improving patient outcomes, preventing staff burnout, cultivating staff resilience, and supporting staff recruitment and retention. Further, psychological safety plays a pivotal role in diversity, inclusion, and belonging¹ — key issues that have become more pronounced in recent years as the focus on various inequities has sharpened.

Simply put, the term "psychological safety" refers to individuals feeling comfortable expressing themselves without fears of being judged, humiliated, ridiculed, punished, or harassed. This expression might come in the form of offering ideas, voicing concerns, asking questions, discussing mistakes, taking risks, and more. How well teams learn together, accomplish goals, and improve performance can largely rely on how psychologically safe they perceive their environments.²

Unfortunately, creating a psychologically safe work culture is not as simple as defining one. An article in Harvard Business Review notes that "One crucial misconception among business leaders is that psychological safety will be present in any reasonably healthy work environment, like freedom from harassment or a commitment to keeping workers injury-free are. In fact, psychologically safe work environments are rare."³

The full realization of a psychologically safe work culture may be elusive due to innate or learned human tendencies, such as fears of being judged or punished, hesitancy to speak up or disagree (especially in a hierarchical structure), and discomfort with taking risks. When these tendencies occur in tandem with an organizational culture that is apathetic or complacent about committing to psychological safety, the opportunity to cultivate an innovative, highly productive, and adaptive workforce diminishes.

Healthcare organizations that are serious about committing to psychological safety should be aware that it is a multilevel concept that must be addressed across the enterprise, within teams, and at the individual level. Three key areas of focus are cultivating leadership support and adoption, implementing strategies and best practices, and providing comprehensive training.

Cultivating Leadership Support and Adoption

Organizational culture often is a direct reflection of its leadership's values, beliefs, and actions. Thus, leadership buy-in and support is critical when endeavoring to create a psychologically safe culture.

Much of the literature discussing psychological safety in healthcare consistently puts leadership (executive-level and team-level leaders) at the forefront of effecting positive changes that promote psychological safety and its benefits. Yet, making the case to invest the time and resources necessary to achieve a psychologically safe environment can be difficult.

A helpful approach involves focusing on tangible outcomes "to make the case that the quality and candor of conversation matters for results."⁴ For example, emphasizing how psychological safety helps address some of the most significant challenges in healthcare — such as improving care coordination and reducing staff absenteeism and turnover — can prove more meaningful to leaders than less-measurable benefits that contribute to those outcomes (such as staff morale or empowerment).

Beyond just demonstrating support for creating a psychologically safe environment, it's also critical to have leaders that represent the tenets of psychological safety through their actions and behaviors. An article from Medical Group Management Association notes that "While psychological safety is everyone's responsibility, it is imperative that leadership, from CEO to front-line supervisor, model behaviors that create and sustain a psychologically safe workspace."⁵ To do this, leaders can employ various strategies, such as:

• Allowing staff to speak freely, listening with respect, and acknowledging employees' contributions
• Being accessible, available, and approachable to employees to encourage open communication
• Encouraging participation and establishing the expectation that team members should contribute to discussions and engage in dialogue
• Modeling vulnerability by admitting mistakes, acknowledging knowledge deficits, and asking for help
• Fostering a nonpunitive environment that approaches errors, mistakes, and failures as learning opportunities
• Setting expectations for professional and ethical behaviors and modeling those behaviors, while also addressing violations quickly and consistently⁶

A top-down approach to psychological safety, in which leaders at all levels support and embody key core values and behaviors, will help reinforce the organization's commitment to culture improvement and its expectations for the workforce.

Implementing Strategies and Best Practices

Incorporating psychological safety into your organization's overall culture of safety might feel like an overwhelming and laborious task. Yet, if it's approached with the same mindset as other quality improvement (QI) initiatives, a series of actionable steps can move the process forward and prevent it from derailing.

First, those involved in devising and implementing strategies for change should have well-developed knowledge about the concept of psychological safety and what it represents in the healthcare setting. The team may find it helpful to clearly define, in writing, the organization's values and goals related to psychological safety. When values and goals are established, the team can determine the capabilities and characteristics that must be cultivated to reach those goals (e.g., open dialogue, mindful listening, situational awareness, empathy, compassion, integrity, and dignity).⁷

Next, as with many QI tasks, assessment of the current state is vitally important. Evaluate your organization's current culture of safety and seek staff insight regarding key components of psychological safety, such as their comfort level with asking questions, raising safety concerns, suggesting new ideas, discussing different perspectives, and reporting issues without fear of retaliation.

Periodic staff surveys, focus groups, discussion forums, and team meetings are various options for collecting data and soliciting feedback. Further, implementing a method that allows workers to provide confidential feedback may help generate more truthful and candid observations.⁸

Review the data and feedback to identify the barriers, issues, and deficits that hinder psychological safety in the workplace. This knowledge will help the implementation team devise appropriate action plans and determine where to focus time and resources. Some important areas of focus might include:

• Ensuring your organization's code of conduct is clearly communicated and establishes expectations for respectful, professional behavior. The code of conduct also should explicitly define unacceptable and detrimental behaviors and their potential consequences.
• Evaluating systems and processes designed to defend and protect employees from biased behavior within the organization or from patients.
• Establishing reliable, consistent processes for reporting, investigating, documenting, and following up on policy violations.
• Implementing and promoting support programs, including peer support (e.g., buddy systems), behavioral health services, and relationship-building opportunities.
• Considering innovative leadership teams and models that include key representatives from various departments or areas to address barriers associated with hierarchy and lack of representation.
• Finding opportunities to improve and encourage collaboration and cohesion amongst peer-level employees and between leaders and their teams to foster open communication, awareness, respect, and familiarity.
• Supporting diverse types of communication and information-sharing that range from large group discussions to one-on-one conversations, with the knowledge that not every employee will have the same comfort level in each situation.
• Reinforcing the value of all team members and making sure employees who are vulnerable to low psychological safety (e.g., junior employees, employees in support roles, and historically marginalized employees) are encouraged to provide perspectives and input.
• Encouraging employees to engage in personal strategies that support psychological safety, such as using stress management techniques, taking breaks and time off, and adopting coping strategies.⁹

Creating a psychologically safe culture is not achieved overnight; rather, it is an ongoing process that requires evaluation, measurement, reevaluation, and adjustment. As with any long-term venture, maintaining leadership and employee engagement can be difficult. However, routine communication about ongoing initiatives and continued support for an environment that rewards the principles of psychological safety can help keep the long-term goals in sight.

Providing Comprehensive Training

The characteristics of a psychologically safe culture require individuals working in the environment to have particular skills and capabilities, which are not always innate. Many of the soft skills associated with psychological safety — such as mindful listening, situational awareness, emotional intelligence, candor, and perspective-taking — require practice and training.

Organizations hoping to achieve psychological safety should offer ample training at both the individual and team levels for workers in various roles, including leadership roles. Trainings should focus on key skills that help promote and nurture psychological safety, and they should allow participants to practice those skills without judgment. Training for leaders and managers also should look at various approaches to leadership and how they might affect the full realization of psychological safety. For example, leaders who take a consultative and/or supportive leadership approach might have better results creating a positive culture than leaders who take an authoritative approach.¹⁰

Because not everyone learns in the same way, offering a variety of training options in different formats is beneficial for participants. However, regardless of format, trainings should be engaging and focus on creating emotional, revelatory experiences that will help learners adjust their mindsets, understand different perspectives, and modify behaviors. Trainers and participants also should consider ways to carry learning into day-to-day work to support the practical application of skills rather than just knowledge retention.¹¹

In Summary

Psychological safety is a crucial component of a robust culture of safety. Yet, the journey to achieving a psychologically safe working environment is complex and will undoubtedly require time, resources, leadership support and modeling of desired behaviors, staff engagement, and a commitment to ongoing training. Healthcare organizations that make these investments can experience many benefits, including a more positive and productive workforce, improved innovation and flexibility, better quality of care for patients, reductions in staff burnout and turnover, and progress toward diversity, inclusion, and belonging.

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¹ Edmondson, A. C. (2020, June 22). The role of psychological safety in diversity and inclusion. Psychology Today. Retrieved from www.psychologytoday.com/us/blog/the-fearless-organization/202006/the-role-psychological-safety-in-diversity-and-inclusion

² France, T. J., Matt-Hensrud, N. N., Menaker, R., & Peters, M. T. (2020, June 10). Cultivating psychological safety: Activating humanness in healthcare. Medical Group Management Association. Retrieved from www.mgma.com/resources/human-resources/cultivating-psychological-safety-activating-human

³ Edmondson, A. C., & Hugander, P. (2021, June 22). 4 steps to boost psychological safety at your workplace. Harvard Business Review. Retrieved from https://hbr.org/2021/06/4-steps-to-boost-psychological-safety-at-your-workplace

⁴ Ibid.

⁵ France, et al., Cultivating psychological safety: Activating humanness in healthcare.

⁶ Ibid.

⁷ France, et al., Cultivating psychological safety: Activating humanness in healthcare; De Smet, A., Rubenstein, K., Schrah, G., Vierow, M., & Edmondson, A. (2021, February 11). Psychological safety and the critical role of leadership development. McKinsey & Company. Retrieved from www.mckinsey.com/business-functions/people-and-organizational-performance/our-insights/psychological-safety-and-the-critical-role-of-leadership-development

⁸ France, et al., Cultivating psychological safety: Activating humanness in healthcare; U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2021, August 6 [last reviewed]). Creating a caring workforce culture: Practical approaches for hospital executives. Retrieved from www.phe.gov/Preparedness/planning/abc/Pages/hospital-exec-practical-approaches.aspx

⁹ Institute for Healthcare Improvement. (2021, November 2). Improve staff joy in work through organizational equity. Retrieved from www.ihi.org/communities/blogs/improve-staff-joy-in-work-through-organizational-equity; Institute for Healthcare Improvement. (2020). "Psychological PPE": Promote health care workforce mental health and well-being. Retrieved from www.ihi.org/resources/Pages/Tools/psychological-PPE-promote-health-care-workforce-mental-health-and-well-being.aspx; O'Donovan, R., & McAuliffe, E. (2020). Exploring psychological safety in healthcare teams to inform the development of interventions: Combining observational, survey and interview data. BMC Health Services Research, 20, 810. https://doi.org/10.1186/s12913-020-05646-z; France, et al., Cultivating psychological safety: Activating humanness in healthcare; U.S. Department of Health and Human Services, Creating a caring workforce culture: Practical approaches for hospital executives.

¹⁰ De Smet, et al. Psychological safety and the critical role of leadership development.

¹¹ Ibid.

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